PROJECT SUMMARY Necrotizing enterocolitis (NEC) is a devastating disease affecting premature infants. Approximately 10% of infants born under 1500 g will develop the disease, and mortality for affected infants is 20-30%. Despite decades of research, the morbidity and mortality of the disease remain generally unchanged. Current treatment and preventive approaches for NEC remain suboptimal, with no FDA-approved therapies for the indication. NEC is the leading cause of death from gastrointestinal disease in premature infants, with an associated cost of $500 million to $1 billion annually for treatment in the US alone. Given the morbidity and mortality associated with the disease and the resulting economic burden, novel approaches for the prevention of NEC are critically needed. Probiotics hold enormous potential for promoting human health and treating disease, including NEC. Current probiotic approaches are inadequate due to the lack of persistence in the gut which necessitates multiple administrations of the probiotic and results in limited efficacy. This creates a safety concern for this vulnerable neonatal population since probiotic administration has been linked to bacteremia. Concern for potential sepsis is one of the major factors limiting widespread use of probiotics by neonatologists to prevent NEC. Scioto Biosciences and their research partners at the Research Institute at Nationwide Children?s Hospital (RINCH) are developing a novel probiotic approach, SB-121, that allows for persistent probiotic benefit from just a single dose well in advance of NEC and the corresponding changes in intestinal permeability, thus dramatically reducing the risk of bacteremia. SB-121 is a biofilm of Lactobacillus reuteri, a persistent community of bacteria, adhered to porous microspheres enabling increased probiotic stability. In a successful Phase I program, Scioto Biosciences met all Phase I milestones resulting in: 1) the production of a stable SB-121 prototype that supports clinical use of the platform; 2) the in vivo demonstration of the effectiveness of SB-121 in preventing NEC; and 3) the identification of optimal SB-121 dosing. Completion of the Phase I program was critical to supporting the proposed Phase II program that will focus on the execution of studies in neonatal pigs. This will inform clinical studies as neonatal pigs are similar in size and intestinal maturity to premature humans. Phase II efforts will include the characterization of the impact of SB-121 on the microbiome and metabolome of healthy full-term and premature pigs (Aim 1) and the assessment of the ability of SB-121 to prevent NEC (Aim 2). Successful execution of the Phase II program will provide critical dose, safety, and efficacy data packages that will be instrumental to the design and execution of a subsequent IND-enabling program, as well as clinical trials supporting the clinical use of SB-121 for the prevention of NEC.